The following questionnaire encompasses many aspects of the lives of the alcoholic/addict as well as their family. Please check and comment on the items listed below as applicable to the individual’s use of alcohol/drugs and/or other mood altering chemicals. Your comments on these questions will help us gain a more complete understanding of the individual’s problem. Even though some of the questions may seem obvious, it is important to keep in mind the individual may not be aware of his or her own past behavior. Please be specific and answer every item, giving examples wherever possible.
Individual’s Name:_____________________________________________________________
Your Name:_________________________________ Your age:_____
Your Phone #: Home ( ) ___ Cell (_____) Work: ( )
Your e-mail address:________________________________________
What is your relationship to the individual?
__Spouse __Significant Other __Child __Mother __Father __Sibling __Friend __Other:
How many years have you been in this relationship?
Would you consider your relationship a happy relationship except for the drinking and/or drug use? __Yes __No
Please explain:
Are you living with the individual at the present time? __Yes __No
If yes, do you plan to continue living with the individual? __Yes __No
Have you given the individual an ultimatum? __Yes __No
If you are married to the individual, how many times have you been married?
How many times have you and the individual been separated or lived apart?
Do you and the individual have children? __Yes __No
Are there any children from previous relationships? __Yes __No
Please list the names and ages of the children:
Name Age Living at Home
__Yes __No
__Yes __No
__Yes __No
__Yes __No
Do any of the children seem to have personality or emotional problems? ‡ Yes ‡ No
Of what nature:
Do any of the children seem to have difficulties or problems in school ‡ Yes ‡ No
Explain:
FAMILY QUESTIONNAIRE/ASSESSMENT
PAGE TWO
Is any family member, besides the individual, presently seeking professional help for emotional or behavior problems? ‡ Yes ‡ No
If yes, please identify them:
Do any family members other than the individual, drink or use drugs to excess? ‡ Yes ‡ No
If yes, please identify family members:
What drugs are you aware the individual has used or is using: ‡ Alcohol ‡ Marijuana ‡ Tranquilizers
__Sleeping pills __Pain pills __Methamphetamine/Speed/Crystal __Cocaine/Crack
__Heroin __Methadone __Hallucinogens
__Other: What is the individual’s drug of choice ?:_____________________________
How long have you been aware of the individual’s alcohol/drugs use ?:____________
Has the individual had previous treatment for chemical dependency/addiction? __Yes __No
How many times? Where? When?
Length of stay? How long was he/she sober?:_______________________________
Has the individual expressed feelings of remorse, guilt, depression or suicide? __Yes __No
Please explain:______________________________________________________________
__________________________________________________________________________
Has the individual’s drinking and/or drug use interfered with social relationships with friends?
__Yes __No
Explain:______________________________________________________________________
_____________________________________________________________________________
Has the individual’s drinking and/or drug use interfered with his/her employment?
__Yes __No __Unemployed __Cannot hold a job __Terminated
__Employer mandated treatment __Suspended
Are you aware of any legal issues due to individual’s alcohol/drug use? ‡ Yes ‡ No
What are they?
The individual’s chemical use has affected? ‡ My job ‡ My health ‡ Our relationship
Please explain:
What steps have you taken to deal with the individual’s chemical use?
__I have sought help from a doctor, therapist, clergy, psychiatrist, etc.
__I have discussed the problem with family members.
__I have attended or I am attending Al-Anon or other 12-step programs.
__I have left or threatened to leave.
__Other:
Has the individual engaged in acts of physical violence? __Yes __No
Explain:_______________________________________________________________________
_________________________________________________________________________________________________
What is your view of yourself?
__I suffer from fears and anxieties about the individual a lot of the time.
__I rarely feel angry, hostile, or resentful toward the individual.
__I feel that the individual loves me deeply.
FAMILY QUESTIONNAIRE/ASSESSMENT
PAGE THREE
My use of alcohol is best characterized as:
__I never drink.
__I rarely drink or drink only socially.
__Sometimes I drink to relax.
__I drink two or more drinks a day.
__Drinking is a problem for me.
I have used, or am using:
__Marijuana
__Tranquilizers
__Methamphetamines
__Pain medications
__Other:
Has your chemical use increased to keep up with the individual or to deal with the outcome of the individual’s drug/alcohol use? __Yes __No
What are you expectations regarding the individual’s disease and recovery?
Specific issues I feel I am dealing with include:
__Denial
__Minimizing
__Anger/Resentment
__Dependency in relationship
__Individual’s resistance to recovery
__Other (be specific):
Have you ever attended Al-Anon? __ Yes __ No
Is there a person, or persons, you have concerns about visiting the individualwhile at Inpatient?
__Yes __No
If so, please provide the name(s):__________________________________________________
__________________________________________________________________________________________________
If the individual should choose to leave against staff advise:______________________________
Who would you want contacted?_____________________________________________________
(Name) Relationship Home Phone/Cell Phone:__________________________________________
What family member/friend would be most likely to pick him/her up?_______________________
What family member/friend would be least likely to pick him/her up?_______________________
We welcome any suggestions, concerns, or questions you have: